Exam 1 - Errors Flashcards
What is a medication error?
Any preventable event that may cause/lead to inappropriate med use or pt harm
Occurs when medication is in control of any of the following:
- healthcare professional
- patient
- consumer
What does MICRO patient safety involve?
Looking at a whole patient
- abbreviations
- labeling
- dispensing meds
- admin
What does MACRO patient safety involve?
Just culture
System processes
What is a medication misadventure?
Any unintended and harmful event involving medication
Includes:
Errors
ADRs
Side effects
Can occur during prescribing, dispensing, or admin
What does medication misadventure encompass?
All forms of med related incidents, whether they’re preventable or not
Adverse drug event (ADE)
Unexpected SE to a drug that is NOT expected
What can ADEs result from?
Medication errors
ADRs
Overdoses
These can occur during prescribing, dispensing, or admin
Adverse drug reaction (ADR)
Reaction to a med that is considered a risk or SE
ADRs are NOT due to ____
Errors
(They are SEs or risks that are expected when taking the drug — you didn’t do anything wrong, it just happens sometimes)
What is a close call/near miss?
Event/situation that COULD have resulted in harm to a pt but did NOT
Happens either by chance or because it was caught and corrected before causing damage
Why are close calls and near misses important to analyze?
The reveal potential system weaknesses/risks in medication process that could lead to harm if they are not addressed
(If something bad could’ve happened because of a weak spot in the system, eventually it will happen)
What are look-alike, sound alike meds (LASA) related to
Names of products or packaging
Who publishes the List of Confused Drug Names?
Institute of Safe Medication Practices (ISMP)
What safeguards should be used to reduce risk of LASA med errors?
- Use both brand AND generic names on rx and labels
- Include purpose of med on rx
- Require at least 5 letters to be typed into computer systems (like when you’re inputting the drug)
- Changing appearance of look-alike products
Tall man lettering (TML)
Uses uppercase lettering to distinguish the differences between sound-alike drug names
Also uses color or bolding of words
What did the FDA do in 2001?
Started a name differentiation project that determines if TML should be used on specific products
What are high alert medications?
Meds w/ a heightened risk of resulting in significant pt harm or sentinel events when used in error
What happens in the FDA determined that TML should be used on a product?
FDA requests mfr to make a voluntary label change
Adds drug to FDA list of Established Drug Names Recommended to Use Tall Man Lettering
What do high alert meds require to reduce risk of errors?
Special safeguards
Example of hazardous drugs
Chemotherapy agents
Examples of high alert medications
Opioids (risk of addiction and OD)
Insulin (requires precise and pt specific dosing)
Anticoagulants (too high of dose = high risk of bleeds)
Neuromuscular blocking agents (pyrantel is one of these – it paralyzes worms so it makes sense for it to be high alert)
What are hazardous drugs?
Studies in animals or humans show that exposure has potential for causing:
- cancer
- developmental/reproductive toxicities
- genotoxicity
- harm to organs
(Don’t Get Canned Ham)
What does ad-hoc mean?
“For this” in latin
What does “ad-hoc” typically mean in terms of pt safety?
Typically thought of as “for this purpose only”
What is the potential issue with ad-hoc abbreviations?
They differ in each facility and there is no standardization
What is on the Joint Commission’s “do not use” list?
U, u
IU
Trailing zeros (4.0 mg)
Lack of leading 0s (.4 mg)
MS, MSO4, MgSO4
Why should you NOT use U or u?
It can be mistaken for 0 or cc
What should be used instead of U or u?
The full word “unit”
Why should you NOT use IU?
Can be mistaken for IV or 10
What should you use instead of IU?
Fully write “international unit”
Why should you NOT use trailing zeros?
The decimal point could be missed, resulting in a higher dose - like mistaking 4.0 for 40
What should you do instead of using a trailing zero?
Just don’t do that
4 mg not 4.0 mg
Why should you ALWAYS use a leading zero?
The decimal point can be missed, resulting in a higher dose
Why should you NOT use MS, MSO4, or MgSO4?
They can be confused for one another
What should you do instead of putting MS, MSO4, or MgSO4?
Write “morphine sulfate” or “magnesium sulfate”
When CAN you use trailing zeros?
ONLY when it is required to show the level of precision being reported
(think sig figs)
What is confirmation bias?
Type of cognitive bias that alters how we process & recall info and our decision making
(When you already have your mind made up about something, that’s how you’ll think about it in the future)
What can be considered a confirmation bias?
The tendency to seek others w/ the same belief or info that supports our already formed opinion
(Like asking the group chat if your boyfriend is in the wrong because you know they’ll say yes)
What is the ostrich effect?
Overconfidence in own opinion and “buries head in sand” to avoid contradictory info
(Think anti-vaxxers and how they refuse to acknowledge real sources but will cite like a reddit post or something)
Confirmation bias in personal interpretations
Pre-existing beliefs change how you view situations
(If someone is homophobic and thinks gays are evil, they’ll assume you’re a bad person before they even get to know you)
Confirmation bias in social interactions
Some people get anxious when waiting on a text back
The longer the wait, the stronger the feeling grows of why the person is not answering
(The silence is “confirming” whatever reason you think they aren’t replying)
Confirmation bias in scientific research
Scientists work for years on a hypothesis and may only want to look at positive outcomes or ignore the other results
(Only acknowledging the data that CONFIRMS what they already think)
Confirmation bias in the media
Writers/researchers may used biased info to create a headline
Those w/ the same viewpoint may see it and take that info as fact, thus validating their own point
(Think about the people who post the craziest articles on facebook like “Beyonce was sent by the devil to make your kids gay”)
How can you reduce confirmation bias?
- You can be wrong (accept this)
- Test your hypothesis
- Beware of repetition
What is a proprietary name?
Brand name
What are the steps to having a proprietary name approved?
- Applicant selects proprietary name
- Name is vetted internally or by specialized company
- Applicant submits NDA and name assessment
- Division for medication error prevention and analysis
- Division of drug marketing, advertising, and communications
- Center for drug evaluation and research
- Name approval
(All Night A Dumb Dyke Chews Nips)
What are the parts of an OTC drug label
AI
Purpose
Uses
Warnings
Directions
Other info
Inactive ingredients
Questions/comments (mfr phone #)
What is the non-proprietary name referred to?
United States Adopted Name (USAN)
(Non-proprietary = generic)
What is the non-proprietary name?
Designated for compound used only as a med that is determined by council of members from:
- Manufacturers
- American Medical Assoc (AMA)
- American Pharmaceutical Assoc (APA)
- United States Pharmacopeial Convention (USPC)
Non-proprietary stem words
Common word elements used for all drugs in a specific class (ie -sartan is an ARB and -pril is an ACE)
(Non-proprietary = generic and prefixes/suffixes are stems)
Is the non-proprietary name part of the FDA process?
NO
FDA is involved in ensuring BRANDED meds don’t have LASA issues
(This makes no sense?)
Pharmacists should use ___ and consider the patient’s ___
Clinical judgement
Entire clinical profile
(Use what you know about drugs and what you know about the pt)
What should you do if you need clarification on something?
Talk with the provider or patients
Follow your gut feeling
What should pharmacists NOT bypass?
Warnings/reminders without thought
(Alert fatigue)
Where should you store LASA drugs?
In separate places
Use signage to alert staff
Self dividers/bins/compartments to alert people that there is a difference
What should be done with a verbal/phone order?
Limit to only when necessary
ALWAYS do a COMPLETE read back
